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®,ee Stericycle' <br />Protecting People. Reducing Risk: <br />IN CASE OF EMERGENCY CONTACT: CHEMTREC 1-800-424-9300 STANDARD MANIFEST 001 -10 -06 -STD <br />CUSTOMER No. <br />LEANE MT GENERATOR <br />1. Generator's Name, Address and Telephone Number 1 211 Ht <br />f E <br />A 4 A i4 ti� i muP <br />33 1�1 I Nq-; <br />i jzi A- 4 Z 4 19 'i A <br />a <br />N 2� <br />CUSTOMER NUMBER GENERATOR'S REGISTRATION # <br />2A. DESCRIPTION OF WASTE <br />28. CONTAINER TYPE <br />2C. NO. OF <br />2D. VOLUME <br />UN3291, Regulated Medical Waste, ri.o.s.,CONTAINERS <br />�a- % <br />6.2. PGII <br />7 A <br />Cu Ft. <br />UN3291, Regulated Medical Waste, n.o.s., <br />6.2, PGII <br />Cu Ft. <br />CC <br />UN3291, Regulated Medical Waste, n.o.s., <br />0 <br />6.2, PGII <br />Cu Ft. <br />UN3291, Regulated Medical Waste, n.o.s., <br />6.2, PGII <br />Cu Ft. <br />W <br />UN3291, Regulated Medical Waste, n.o.s., <br />-4 <br />Z <br />6.2, PGII <br />Cu Ft. <br />j3 <br />UN3291, Regulated Medical Waste, n.o.s., <br />6.2, PGII <br />Cu Ft. <br />UN3291, Regulated Medical Waste, n.o.s., <br />6.2, PGII <br />Cu Ft. <br />UN3291, Regulated Medical Waste, n.o.s., <br />6.2, PGII <br />Cu Ft. <br />Cu Ft. <br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately T®TALSCu <br />Ft. <br />described above by the proper shipping name, and are classified, packaged, marked and labelled/placarded, and <br />are in all respects in proper condition for transport according to applicable international and national governmental regulations." <br />xPrinted/Typed <br />Name Signature <br />Date <br />4. TRANSPORTER 1 ADDRESS: <br />Phone <br />UJ <br />Applicable Permit Numbers: <br />CCa. <br />0 <br />9L Z <br />TRANSPORTER CERTIFICATION -Receipt of medical waste as described above. <br />4� <br />Print/Type NameX1 <br />Signature <br />Date <br />S. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS: <br />Phone #: <br />"uj <br />LE tR <br />Applicable Permit Numbers: <br />5 Uj <br />Lu _j <br />0 <br />0- Z <br />Cn F= <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />Z X <br />'N <br />CC — <br />Print/Type Name Signature <br />Date <br />Lu <br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: <br />Phone #: <br />umi x <br />Uj <br />Applicable Permit Numbers: <br />zCI <br />Mz <br />0: <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />< <br />wx <br />Print/Type Name Signature <br />Date <br />7. DISCREPANCY INDICATION <br />y-, <br />[JSA. Designated Facility: F� 81B. Alternate Facility: 8C. Alternate Facility: <br />8D. Alternate Facility: <br />7, <br />Z <br />jj <br />TREATMENT FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have <br />received the above indicated wastes in accordance with the requirement outlined in that authorization. <br />Print/Type Name Signature <br />Date <br />LEANE MT GENERATOR <br />